2010 Summer Intensive Program at Nagoya University, Japan
“Latest Advanced Technology & Tasks in Automobile Engineering”
June 15, 2010 to July 21, 2010
APPLICATION FORM
Name:______
last name first name middle name
Date of birth: ______place of birth_______
(month/day/year)
Citizenship: ______ Sex:
Home institution:
Name of Faculty/Department/Graduate School:
Major field: Minor field:
Current status at your home institution
〔 〕Undergraduate Program 〔 〕Junior 〔 〕Senior
〔 〕Master’s program 〔 〕1styear 〔 〕2ndyear
〔 〕Doctor’s program 〔 〕1styear 〔 〕2nd year 〔 〕3rd year
Current Address:
Zip code Country
Phone number: E-mail address:
Mailing address for the acceptance/denial letter and pre-departure information:
(if different from the current address)
Zip code Country
Phone number: Fax number:
Person to be notified in your home country in case of an emergency:
Name in full:
Address:
Home phone number: Fax number:
Cell phone number: Work phone number:
E-mail address: Relationship with the person:
Japanese Language Ability:
1. Have you previously studied Japanese?
Yes No
2. Please answer the following questions regarding the Japanese courses you have taken:
Name of School(s) Period of Study Textbook(s) Lessons
completed
~
~
~
~
3. Approximately how many Chinese characters can you read?
4. If you have passed the Japanese Language Proficiency Test (JLPT), please indicate the level and score that you obtained:
1 1-kyuu 2 2-kyuu 3 3-kyuu 4 4-kyuu Score:
(For Non-native English speaker)
English Language Ability:
1. If English is not your native language, please indicate how many years of English language instruction you have had.
Total of years
2. State the name of any internationally recognised English language examination (i.e., TOEFL, TOEIC, IELTS) taken, and scores obtained:
Examination: Score<s> :
Components:
I certify that all information provided is true and correct to the best of my knowledge. I understand NagoyaUniversity will use this information solely for the purpose of determining participant eligibility and student tracking.
Applicant’s signature Date
2010 Summer Institute Program at Nagoya University, Japan
Name: Date of Birth:
Please answer the questions below by checking the appropriate box, before submitting to a physician for your
physical examination.
1. What diseases, disorders or injuries have you had in the past five years?
2. Have you received any counselling/undergone any treatment for mental health-related symptoms in the last five years? If yes, please specify. Yes/No
3. Do you have any allergies to foods, plants or animals? Please specify. Yes/No
4. Have you ever had an adverse reaction to medication? Please specify. Yes/No
5. Are you taking medication now? Please specify. Yes/No
To the Physician:
Please review the applicant's medical history and complete the information below, giving details concerning any positive indications. If there are any abnormalities in the following systems, circle‘+’ and explain in detail.
1. Head/Ears/Nose/Throat + / − 6. Musculoskeleal + / −
2. Respiratory + / − 7.Metabolic/Endocrine + / −
3. Cardiovascular + / − 8.Neutropsychiatric + / −
4. Eyes + / − 9.Skin + / −
5. Genitourinary
Physician’s Comments:
After reviewing the applicant's medical history and physical condition, I believe him/her to be in good physical and mental health, free of any chronic conditions, disorders or contagious diseases, and capable physically and mentally of completing a six week summer program in a Japanese university.
Physician's signature: Date:
Physician's name <please print>:
Address:
Contact Details: 1) Tel/Fax: 2) E-mail:
2010 Summer Intensive Program at Nagoya University, Japan (NUSIP)
Latest Advanced Technology &Tasks in Automobile Engineering
June 15, 2010 to July 21, 2010
Statement of Purpose
A brief description of why you want to participate in the summer program:
Applicant’s signature Date